STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 5ist Street It paying by cred card, enter the amount you are paying in the remitlence bex and | fll out Betow. 7th Floor Mastercard Vise Amex | New York NY 10019 —_ --- _ | Jeff Epstein J a dis [Date Account | P.O. Box 806 4/30/2014 | New York NY 10150 ~ ~ Remittance IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Corde Ep De Signaare Sig Cove Date ~ Patient Description ] Charges ] Credits Balance 3/27/2014 Previous Balance 0.00 4/23/2014 | Jeff 1 Periapical X Ray 25.00 | 25.00 4/25/2014 | Jeff surgical extraction 1,200.00 | 1,225.00 4/25/2014 | Jeff Gum Graft 1,200.00 2,425.00 4/29/2014 180.00 2,605.00 4/29/2014 40.00 2,645.00 4/29/2014 175.00 | 2,820.00 | ' Account Total 2,820.00 \f payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and return the top part of this statement, or call the office a’ Current 30 Days | 60 Days 90 Days | 120+ Days 2,820.00 | 0.00 | 0.00 | 0.00 | 0.00 Thomas J. MagnaniD.D.S. Alvin Grayson0.D.S. 7 WestSistStreet 7thFloor New York NY 10019 FY EFTA00311292